| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,029 |
1,010 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
768 |
746 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,058 |
1,036 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
1,099 |
1,088 |
$18K |
| D1120 |
Prophylaxis - child |
521 |
515 |
$10K |
| D0330 |
Panoramic radiographic image |
286 |
271 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,896 |
1,823 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
88 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
571 |
567 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
255 |
228 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,669 |
1,479 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
67 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
78 |
42 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
179 |
$4K |
| D0272 |
Bitewings - two radiographic images |
129 |
129 |
$1K |
| D0350 |
|
20 |
18 |
$196.96 |